Ashbury Lodge Residential Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We reviewed 7 quality statements relating to shared direction and culture, capable and compassionate leaders, freedom to speak up, workforce equality, diversity and inclusion, governance, management and sustainability, partnerships, communities, and learning, improvement and innovation. We found changes in leadership had impacted staff. Mechanisms had recently been put in place to allow people, relatives and staff to speak up and have their voices heard. The provider had liaised with various health professionals to provide safe care and treatment for people. Initiatives had been put in place to work with the local community. Policies and procedures were compliant with legislation and good practices. There were governance, management and accountability arrangements in place. However, we found improvements were still needed in relation to care plan audits. The audits were not effective and did not ensure relevant, consistent, and up to date information was available to inform staff and keep people safe.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they had been involved in developing the strategy, visions, aims and values. One staff member told us the culture “is ok at the moment; we work as part of a team, and I like that.” Another staff member told us “I definitely get on well with everyone now, the whole team works well together, if they need help, they will ask.” Leaders told us there were “developments every week with all of our strategies and aims. The vision is ongoing.” The area manager told us they were “supporting the home with ideas, guidance and planning for the development of the service.” The service gained feedback from residents on changes to the service which was fed into the strategy.

There was a business plan, vision and strategy in place. There was a service improvement plan in place which identified some of the concerns we found during the assessment. The service was working through the actions in the plan.

Staff told us the various changes to leadership during a short period of time had impacted them and the service. One staff member told us “One manager wants one thing then someone else the other” and “it is frustrating.” Staff told us leaders were visible and the current manager had provided stability for the service. Leaders told us they were in the process of recruiting a permanent registered manager. A new deputy manager has been recruited and was due to commence in June 2024.

Leaders understood the issues and priorities for the quality of the service. The peripatetic manager was able to access support from the area manager to be able to deliver in their role. At the time of the assessment the service was actively recruiting for a registered and deputy manager.

Staff told us they were able to speak up and have their voices heard. They had regular opportunities through staff meetings, handovers and supervisions to express their views. The peripatetic manager told us “We have an internal speak up voice where staff can speak to Coate Water Care with their concerns. We have posters in the home on how people can put their concerns through.” They also told us staff can approach the peripatetic manager or area manager and there was an open-door policy.

There were two recent surveys which staff participated in. The survey results were reviewed by the peripatetic manager and area manager, and action plans had been created from the responses. The service had recently engaged with residents and relatives about their views of the service. However, one relative told us they had not been previously consulted on their views and they had not been made aware of any resident’s meetings. Supervisions showed staff were able to have their voices heard. There was a whistleblowing policy in place.

Staff showed a good understanding of equality, diversity and inclusion. One staff member told us “They don’t discriminate and want my opinions about things. Some environments I’ve been in you can’t bring things up at all, but here I can. I feel inclusion in my place. The residents try and understand you and I know that can be difficult but it’s important that we are kind and respectful to one another and communicate. There has been no discrimination in the home.”

There were policies and procedures in place to support workforce equality, diversity, inclusion and bullying and harassment.

The peripatetic manager and staff understood their roles and responsibilities and had opportunities to discuss their roles during supervisions and team meetings. Staff were aware of when to gain consent for publishing material about the home on social media. Staff were aware of how to record information and how to keep people’s data safe. However, staff told us that due to the changes in management this had affected governance in areas such as care plans.

There was a policy and procedure in place for the availability, integrity and confidentiality of date, records and data management systems. Audits were being completed by the provider. However, we found some of the audits completed were not effective and had not identified the concerns we found. Improvement was still needed in relation to keeping care plans up to date and accurate to provide safe care and treatment for people.

People received ongoing support from various external health and social care professionals who represented them.

Staff and leaders understood their responsibilities to work in partnerships with external care professionals to ensure people received joined up care. The area manager told us there was “previously a lack of integration with the community” and “during 2024 they wanted to bring the community into the home.” The service had recently communicated with a local primary school and gifted them with resources for pupils to produce artwork for the home. The resulting artwork was on display in the home and there were plans for the pupils to visit the home shortly to see it.

A health professional told us “I have always found the team there very helpful and accommodating. They appear professional and caring towards the residents and know their residents very well. I do sometimes find it hard to get through to the staff when I attempt to call and book an appointment. I do not always get a call back from the team when I have requested them to call back.”

There was evidence in the care plans and daily notes the provider had liaised with various health professionals to ensure safe care and treatment for people living in the service. The service was looking at arranging more outside events for people and a summer fair had been planned.

Staff and leaders told us they had recently changed the structure in the kitchen after feedback from people, relatives and staff. The chef’s hours had been amended to allow homemade hot meals for lunch and dinner, alongside a variety of lighter options. Lunch and dinner times had become main events in the home with a variety of choices on offer. This resulted in people becoming more engaged in their food and mealtimes.

Staff had received training relevant to their roles. There was a refurbishment plan in place where people had been involved in making decisions about the decoration in their own rooms and other areas. There was evidence of reflective practice where things had gone wrong which ensured lessons had been learned.